Managing a Portfolio of

Sept. 30, 2013

2:00 to 3:00 pm CST

Managing a Portfolio of

Improvement Efforts

Speakers

• Steve Tremain, MD, FACPE: Cynosure Health

• Cindy Johnson, RN: Sierra Vista Hospital

• Kim Werkmeister, RN, BA, CPHQ: Cynosure • Kim Werkmeister, RN, BA, CPHQ: Cynosure

Health

• Denise Remus, PhD, RN: Cynosure Health

2

Managing a Portfolio of

Steve Tremain, MDPhysician Improvement Advisor, Cynosure Health

Managing a Portfolio of

Improvement Efforts

What’s an

Improvement Portfolio?

• The pool of different improvement efforts by

which a health care organization attempts to

make care safe, timely, effective, efficient,

equitable, and/or patient centered.equitable, and/or patient centered.

Why Is This Important?

• The #1 barrier to measuring, reporting, and

reducing harm from additional hospital

acquired conditions is that it is too much

work, especially for small hospitalswork, especially for small hospitals

Why Is This Important?

• Most common is the centralized PI model

where one or more people in the PI dept do

most or all of the work

• This is not sustainable beyond a few

conditions

Centralized Distributed

Data Collection PI Dept Macrodata: PI

Small test of Change data:

Local dept

Data Interpretation PI Dept All

Intervention Design PI Dept Local DeptIntervention Design PI Dept Local Dept

PI Dept Role Do-er Coach

Level of Hosp Dept

Engagement Low High

Level of Clinician

Engagement Few Many

Ownership PI Dept Everyone

Managing a Portfolio of

Cindy Johnson, RNInfection Preventionist, Employee Health, Nurse Utilization Manager

Sierra Vista Hospital

Truth or Consequences, New Mexico

575-743-1331

cindy.johnson@svhnm.org

Managing a Portfolio of

Improvement Efforts

Who Are We?

• 15 bed Hospital with Swing Bed Capability

• Average In-Patient Length of Stay – 2.4 days

• Dedicated Emergency Department

• Connected Rural Health Clinic and Behavioral Health Clinic

• Connected Rural Health Clinic and Behavioral Health Clinic

• Own the only Ambulance Service for the County

(one of the largest counties in the state)

• Only hospital service available for 100-mile radius

• Located in rural New Mexico; along major north-south interstate highway; near largest lake in the state

Challenges

Our size – we are so small that….

• Our numbers easily skew

• It is easy to overwhelm and overload individuals

So many measure between HEN and CORE measures that staff were overwhelmed

Difficult to engage staff for tests of change and consistency in performance

Benefits

• We have improved patient care

– Falls and Readmission rates are down

– CAUTI has improved our Foley related – CAUTI has improved our Foley related

documentation and process

– Pressure Ulcers – discovered issues we were not

aware of

– VTE – hope to improve our prophylaxis use

What Has Worked?

Initially – tried to separate all HEN and CORE

activities

• Problem – too many meetings, not enough • Problem – too many meetings, not enough

time

• Problem – the list is so long when you combine

HEN and CORE Measures

What Has Worked?

Now – Simplify the reporting process and combine the tasks

• Meet weekly – HEN one week, CORE Measures the next.the next.

• Combine HEN and CORE tasks – most of them coincide.

• Chose project leaders and assign a specific measure.

Leaders implement tests of change and report back to team.

REPORT FOR OPI COMMITTEE

CORE MEASURES Inpatient

Core Measures

Outpatient

Core Measures

Meaningful Use

Hospital

Meaningful Use

Clinic

QHi

HEN

AMI * median time to Fibrinolysis

*Fibrinolytic therapy received

30 minutes from arrival

*median time to transfer

*aspirin at arrival

*median time to EKG

*Troponin results within 60

minutes of arrival

Heart Failure

*ACEI or ARB for LVSD

*LVF Assessment

*Discharge Instructions

Pneumonia

*blood cultures x2 before

antibiotic

AMI *median time to Fibrinolysis

*Fibrinolytic therapy received

30 minutes from arrival

*median time to transfer

*aspirin at arrival

*median time to EKG

*Troponin results within 60

minutes of arrival

Chest Pain

*aspirin at arrival

*median time to EKG

*Troponin results within 60

minutes of arrival

Pain Management

*ED – median time to pain

Physicians:

* Maintain Up-to-date

problem list

* Computerized

Provider Order Entry

Nursing:

* Maintain current

Allergy and Medication

list

* Record Vital Signs /

Body Mass Index

* Smoking Status /

Smoking Cessation

* Electronic Copy of

Discharge Information

Registration:

* Maintain Current

Physicians:

* Maintain Up-to-date

problem list

* Computerized

Provider Order Entry

Nursing:

* Maintain active

Allergy Medication

List

* Patient specific

education resources

provided

* Vital Signs/Body

Mass Index

* Smoking Status

Registration:

* Maintain current

Percentage of

Readmissions Within

30 days with same or

similar Diagnosis

Percentage of ER visits

within 72 hours of same

or similar diagnosis

CHF - Discharge

Instructions

Pneumonia Patients *

Receiving Initial

Antibiotic Within 6

Hours of Hospital

Arrival

Preventable Readmissions

Pressure Ulcers

* Patients with skin assessment

documented within 24 hours of

admission.

* Patients with hospital

acquired St. II or higher

pressure ulcer

antibiotic

*antibiotic within 6 hrs of

arrival

*antibiotic selection

Stroke *Venous thromboembolism

prophylaxis

*ED t-PA admitted within

3 hours

*anticoagulation therapy for

A-Fib

*Thrombolytic therapy

*Antithrombotic therapy by

end day 2

*discharged on statin

medication

*discharged on antithrombotic

therapy

*stroke education

*rehab assessment

*ED – median time to pain

management for long bone

fracture

ED Throughput

*median time from ED

arrival to ED departure for

discharged ED patients

*transition record with

specified elements received

by discharged patients

*Door to diagnostic

evaluation by a qualified

medical professional

*ED-patient left without

being seen

* Maintain Current

Demographics

Tracking:

* Patient Specific

Education Resources

* Advanced Directives

* Transition of Care

summary

Structural

Measures:

*ability to receive lab

data Electronically

*tracking clinical results

between visits

* Electronic Copy of

health Information

* Maintain current

Demographics

* Patient reminders

Tracking:

* Timely Access (time

till seen by physician)

Structural

Measures:

*ability to receive lab

data Electronically

*tracking clinical results

between visits

* Electronic copy of

Health information

* Clinical summaries

Arrival

* Initial Antibiotic

Selection for

Community - Acquired

Pneumonia (CAP) in

Immunocompromised

Patients

* Pneumococcal

Immunization – for all

inpatients Age 65 and

Older

Unassisted Patient

Falls per 100 Inpatient

Days

Reducing Fall Risks

Inpatient

Core Measures

Outpatient

Core Measures

Meaningful Use

Hospital

Meaningful Use

Clinic

QHi

HEN

VTE *prophylaxis ordered

*patients w/anticoagulation

overlap therapy

*discharge instructions

*incidence of potentially

preventable VTE

*platelet count

ADE-CPOE *number of inpatients with

medications ordered through

CPOE

Stroke:

*ED – Head CT scan results

for acute ischemic stroke or

hemorrhagic stroke who

received interpretation within

45 minutes of arrival.

Imaging Items pulled from CMS Billing

*MRI lumbar spine for low

back pain

*Mammography follow-up

Rates

*Abdomen CT use of

contrast material

*Thorax CT use of contrast

Material

*Cardiac imaging for pre-op

risk assessment for non-

cardiac low-risk surgery

*simultaneous use of brain

Clinical Measure:

* Adult weight

screening and follow

up

* Preventive care and

screening measure pair:

Tobacco use assessment

and tobacco cessation

intervention

* Hypertension: Blood

pressure measurement

Influenza Vaccine -

for all in-patients

HAE (Hospital

Acquired Event)

*Healthcare Associated

Infections per 100

Inpatient Days (Not

Present On Admission)

- CAUTI

- CLABSI

- Pressure Ulcers

- Hosp Acq. Pneumo

- VTE's

- C-Diff

VTE *prophylaxis ordered

*incidence of potentially

preventable VTE

ADE : *Hypoglycemia in inpatients

receiving insulin or other

hypoglycemic agents.

* CPOE: Number of

inpatients who have at least

one medication ordered using

computerized provider order

entry

*Medication Reconciliation:

Number of inpatients with

medication reconciliation

completed ad admission.

*simultaneous use of brain

and sinus CTs

*use of brain CT in the ED

for atraumatic headache

Surgery:

*timing of antibiotic

Prophylaxis

*prophylactic antibiotic

selection for surgical patients

What Has Worked?

Engaging staff: Team leaders were engaged but

not all staff.

Solution: Pull front line staff into the meetings.

Go to them when they can’t come to you.

Managing a PI Portfolio in an

Kim Werkmeister, RN, BA, CPHQ

Managing a PI Portfolio in an

Environment of Competing Priorities

How do you determine a

true priority?

And

How do you fit those

priorities into the

portfolio?

Priorities Priorities

Determining

Priority Priority

Status

Characteristics of a Good

Matrix

• Identifies measures that fit within the

organization’s strategic goals

• Identifies those measures that support the

highest risk and most problem-prone areashighest risk and most problem-prone areas

• Tracks measures related to past accreditation,

licensing and risk areas

• Has a clearly defined system of measurement

within the matrix

With So Many Priorities, How

Do We Fit Them All In?

Step 1

Take an inventory

Step 2

Use a matrix to prioritize

Step 3

Divide and conquer

Divide and Conquer

Maximize measures – use the inventory to

leverage your bench talent

Divide and Conquer

Calendar data sampling and focused reviews

Divide and Conquer

Assign ownership appropriately – so everyone

knows who’s “Got It”

Managing Quality Improvement

Denise Remus, PhD, RNImprovement Advisor, Cynosure Health

Managing Quality Improvement

Across a System

System Structure

30

Common Challenges

• Multiple, often conflicting priorities

• Silos

• Top down

• “Flavor of the month” • “Flavor of the month”

• “I can wait it out”

31

Solutions

• Align

– Strategic priorities to individual projects

– Board to front-line team

– Compensation– Compensation

• Prioritize

• Communicate

– Consistent, simple messaging

– Transparency

• Leverage system strengths32

Alignment & Prioritization

• Service• Cost

33

• Service

– Patient

experience /

HCAHPS

– Family

engagement

– Employee /

Physician

satisfaction

• Outcome

– Readmissions

– HACs

– HAIs

– Population health

– Unnecessary

hospitalizations

• Cost

– Revenue,

operating margin

– VBP

– HAC penalty

– Readmission

penalty

Consistent Communication

– Board

– C-Suite

– Physicians

– Directors

34

– Directors

– Managers

– Front-line Team

Transparency

• Who, what, where, when, why

35

Leverage System Strengths

• Diverse knowledge & expertise

• Top performers

• Multiple PDSA cycle opportunities

• Resources• Resources

• Standardization

36

Questions?

37